Prevesical peritoneum interposition to prevent risk of rectovaginal fistula after en bloc colorectal resection with hysterectomy for endometriosis: Results of a pilot study

Postoperative rectovaginal fistula: stoma may not be necessary-a French retrospective cohort

BACKGROUND

Postoperative rectovaginal fistula leads to a loss of patients' quality of life and presents significant challenges to the surgeon. The literature focusing specifically on postoperative rectovaginal fistulas is limited. The objective of the present study is to identify factors that can enhance the success of the management of this postoperative rectovaginal fistula.

METHODS

This retrospective multicentric study included all patients undergoing surgery for rectovaginal fistulas, excluding those for whom the etiology of rectovaginal fistula was not postoperative. The major outcome measure was the success of the procedure.

RESULTS

A total of 82 patients with postsurgical fistulas were identified, of whom 70 were successfully treated, giving a success rate of 85.4%. On average, these patients required 3.04 ± 2.72 interventions. The creation of a diversion stoma did not increase the success rate of management [odds ratio (OR) = 0.488; 95% confidence interval (CI) 0.107-2.220]. Among the 217 procedures performed, 69 were successful, accounting for a 31.8% success rate. The number of interventions and the creation of a diversion stoma did not correlate with the success of management. However, direct coloanal anastomosis was significantly associated with success (OR = 35.06; 95% CI 1.271-997.603; p = 0.036) as compared with endorectal advancement flap (ERAF). Other procedures such as Martius flap did not show a significantly higher success rate.

CONCLUSION

The creation of a diversion stoma is not necessary in closing a fistula. ERAF should be considered as a first-line treatment prior to proposing more invasive approach such as direct coloanal anastomosis.

Protective defunctioning stoma in bowel segmental resection at the time of total hysterectomy for endometriosis: when less is more

PURPOSE

To compare postoperative complications in women undergoing total hysterectomy with segmental resection (TH-SR) for intestinal endometriosis with or without protective defunctioning stoma (PDS) confection.

METHODS

Retrospective cohort study conducted at the Gynecologic department of University Hospital of Lille (France) from January 2008 to January 2022 in patients undergone TH-SR for bowel endometriosis.

RESULTS

100 women were considered for the analysis. PDS were performed in 56 women. The rate of rectal resections was significantly higher in the PDS group (p = 0.03). The mean operative time, AAGL scores and length of hospital stay were significantly higher in the PDS group (p = 0.002). The rate of grade III complication according to Clavien-Dindo classification was higher in the PDS group (p = 0.03). Among digestive complications, one case of anastomosis leakage (1.8%) and one case of recto-vaginal fistula (2.3%) was recorded in the non-PDS group, 4 cases of anastomosis stenosis were recorded in the PDS group (7.1%). Persisting bladder atony requiring self-catheterization over one month was the most common disturb (4.6% in the non-PDS group and 7.1% in the PDS group, p = 0.58). The distance of digestive lesion from anal margin was the only risk factor for digestive complications, persistent bladder atony, Clavien-Dindo IIIA and IIIB complications at the multivariate analysis (p = 0.04 and p = 0.06 respectively).

CONCLUSION

No statistically significant differences were found in the rate of digestive complications in case of total hysterectomy and concomitant segmental resection when performing or not preventing stoma.

Intra-operative and post-operative complications of endometriosis excision using the SOSURE approach - A single- surgeon retrospective series of 1116 procedures over 8 years

Background

Endometriosis surgery outcomes have been widely studied, yet heterogeneity in terminology and techniques persist.

Objectives

This study focuses on the perioperative outcomes of a single surgeon using the same structured approach (SOSURE: Survey & Sigmoid mobilisation, Ovarian mobilisation, Suspension of uterus and ovaries, Ureterolysis, Rectovaginal and pararectal space development, Excision of all visible disease) and adheres to the recent standardised terminology proposed by international gynaecological and endometriosis societies.

Materials and Methods

A quality improvement study was conducted retrospectively from January 2015 to January 2023. Data collection involved two databases: the National British Society for Gynaecological Endoscopy (BSGE) database and a more comprehensive locally kept database. The methodology also integrated four endometriosis staging systems.

Main outcome measures

Intra-operative and post-operative complication rates.

Results

Between 2015 and 2023, 1047 women underwent 1116 endometriosis procedures in various UK hospitals with S.K. as primary surgeon. Exclusions totalled 20 due to missing records and specific surgical criteria. The rate of major post-operative complications (Clavien-Dindo grade 3a and 3b) was 1.5% and minor post-operative complications (Clavien-Dindo grade 1 and 2) were seen in 13.8%. No Clavien-Dindo grade 4 or 5 complications were noted.

Conclusion

Our study has shown a low complication rate in endometriosis surgery, despite increasing complexity of surgical cases. This is likely attributed to the surgeon's learning curve, high surgical volume and adherence to a structured approach.

What's new?

Our study demonstrates the learning curve of a surgeon over the course of 8 years. This series involved more than 1000 patients and to our knowledge, is the first to report the complexity of the casemix using four different endometriosis staging systems.

Outcomes of discoid excision and segmental resection for colorectal endometriosis: robotic versus conventional laparoscopy

Surgery for deep endometriosis with colorectal involvement is an option after medical treatment failure. Over the past decade, robotic laparoscopy has emerged as an alternative to conventional laparoscopy. We aimed to evaluate surgical outcomes of robotic versus conventional laparoscopy for discoid excision and segmental resection. From 2019 to 2023, we conducted a retrospective cohort study of 152 consecutive patients with colorectal endometriosis who underwent robotic or conventional laparoscopy for discoid excision and colorectal resection. Ninety of the patients 152 underwent robotic surgery and 62 conventional laparoscopy. The mean total surgical room occupancy and operating times were longer in the robotic group: 270 ± 81 min vs 240 ± 79 min, p = 0.010, and 216 ± 78 min vs 190 ± 76, p = 0.027, respectively. The mean intraoperative blood loss, and the incidence of intra- and postoperative complications (according to Clavien-Dindo classification) were similar in the two groups. The mean hospital stay was greater after conventional laparoscopy (8 ± 5 vs 7 ± 4 days; p = 0.03), and the rate of persistent voiding dysfunction was higher in the conventional group (9/11, 25% vs 2/11, 5%; p = 0.01). A higher incidence of persistent voiding dysfunction was also observed after segmental resection by conventional laparoscopy (25% vs 4.8%, p = 0.01). Our results support the use of robotic surgery as an alternative to conventional laparoscopy for discoid excision and segmental resection for colorectal endometriosis.